EFFECT OF TAMOXIFEN ON ARTERIAL MICROVASCULAR

ANASTOMOSIS
BRENO BEZERRA GOMES DE PINHO PESSOA, M.D.,1* BRUNO BEZERRA MENEZES CAVALCANTE, M.D. (student),2
MUNIQUE PINHEIRO MAIA, M.D. (student),2 HAROLDO H. RIBEIRO FILHO, M.D. (student),2 MARCIA KIYOMI KOIKE, Ph.D.,3
SALUSTIANO GOMES DE PINHO PESSOA, M.D.,1 LUIZ GONZAGA PORTO PINHEIRO, M.D., Ph.D.,4
and EDNA FRASSON DE SOUZA MONTERO, M.D., Ph.D.5

Breast reconstruction after cancer treatment is based on the circulation of pedicle and microvascular flaps. This article aimed to verify the
effect of tamoxifen (TMX) pretreatment in arterial anastomosis in rats. Twenty female Wistar rats were equally divided into two groups.
TMX (0.3 mg/kg) was administered to the experimental group for 2 weeks orally. After this period, the right femoral artery was sectioned
and a terminoterminal anastomosis performed. The same procedure was done in the control group, except that the animals received the
vehicle without TMX. One week later, the femoral arteries were inspected for flow through the anastomosis, and the vessel near it was
sent to light microscopic examination. It was observed mild vasculite in both groups. The intimal thickness and total vessel wall in the
TMX-treated group was significantly higher. A real thrombotic effect upon the arterial vascular anastomosis was not observed, eventhough,
TMX induced intimal hyperplasia. VC 2007 Wiley-Liss, Inc. Microsurgery 27:286–288, 2007.

Breast cancer is the most frequent neoplasm in women.1
Adjuvant and chemoprevention therapy utilizing the
selective estrogen receptor modulators (SERM) are the
mainstay breast cancer treatment beside surgery.2 Tamox-
ifen is the first SERM in clinical use and the most stud-
ied drug in breast cancer prevention and adjuvancy.
Tamoxifen efficacy in reducing breast cancer incidence is
attested in many clinical trials over decades.3–6
As a mixed estrogen agonist and antagonist, tamoxi-
fen affects a multitude of clinical conditions, notably an
increased risk of endometrial cancer and vascular events.
Many clinical reports showed an increased risk of venous
and arterial thrombosis in diverse vascular beds as brain
and upper and lower extremity.7–9 The common pathway
to thrombotic and thromboembolic disease in the setting
of tamoxifen therapy is not totally understood. Reduced
levels of antithrombin III, and protein C and S are impli-
cated in the genesis of vascular events.10,11 Paradoxically,
tamoxifen therapy is related to myocardial infarct reduc-
tion, probably because the pathway to atherogenesis and
thrombogenesis are affected in different ways.12
The reconstructive procedures to mammary ablation
are a great advance in the cancer treatment, as it reduces
1
Division of Plastic Surgery, Department of Surgery, Federal University of
Ceara, Fortaleza, Brazil
2
Federal University of Ceara, Fortaleza, Brazil
3
Clinical Emergency Laboratory, Division of Clinical Medicine, University of
São Paulo (USP), São Paulo, Brazil
4
Division of Mastology, Department of Surgery, Federal University of Ceara
(UFC), Fortaleza, Brazil
5
Division of Surgical Technique and Experimental Surgery, Department of
Surgery, Federal University of São Paulo (UNIFESP) São Paulo, Brazil
*Correspondence to: Breno Bezerra Gomes de Pinho Pessoa, Rua Vicente
de Castro Filho, 1540 Agua Fria Fortaleza, Ceara, Brazil.
E-mail: breno_gpp@yahoo.com.br
Received 11 March 2007; Accepted 14 March 2007
Published online 3 May 2007 in Wiley InterScience (www.interscience.wiley.
com). DOI 10.1002/micr.20357
V
C 2007 Wiley-Liss, Inc.
the psychological impact and stigmata of the mastectom-
ized women. Flap reconstruction is totally dependent on
vascular patency. Pedicle thrombosis is a cumbersome
complication of pedicle and microvascular flaps, and ulti-
mately leads to tissue death and jeopardizes the recon-
structive attempt. The concomitant treatment with tamoxi-
fen and reconstructive procedure brought the question
about the possibility of a tendency toward pedicle throm-
bosis in microvascular flap transfer. The purpose of the
present study is to investigate the effect of tamoxifen pre-
treatment in arterial microanastomosis.
METHODS
The study used 20 adult female Wistar rats, weighing
200 6 20 g, and the rats were divided into two groups
with 10 animals each. They were kept upon established
protocol for biomedical research in the experimental sur-
gical laboratory of the Federal University of Ceará. All
animals had access to chow and water ad libitum in a
12-h light and dark cycle. The animals were weighed
before the experiments.
Tamoxifen (0.3 mg/kg) dissolved in sorbitol 10% and
methylcellulose was administered by oral gavage daily to
the experimental group, for 2 weeks prior to the surgical
procedures. The same preparation, except for the tamoxi-
fen, was administered to the control group concomitantly
through the same route.
The animals were anesthetized with ketamine (50 mg/
kg) and benzodiazepine (5 mg/kg) intraperitonially. The
right groin was prepared with iodinated solution and
the femoral vessels dissected. The femoral artery was
separated from the vein, and a standard terminoterminal
anastomosis was performed utilizing 11-0 nylon monofila-
ment, eight stitches per anastomosis, microsurgical instru-

Figure 1. Photomicrograph show-
ing intimal hyperplasia in the ta-
moxifen group (A: HE 3100).
Detail (B: 3400). [Color fig-
ure can be viewed in the online
issue, which is available at www.
interscience.wiley.com.]
ments, and D.F. Vasconcelos surgical microscope with
253 magnification in both groups. All anastomosis were
performed by the same surgeon.
One week later, the surgical wound was inspected for
healing complication. The criteria described by McNamara
et al.13 were utilized as follows: Grade 0 ¼ complete
wound dehiscence; Grade 1 ¼ 50–75% ulceration; Grade
2 ¼ 25–50% ulceration; Grade 3 ¼ <25% ulceration;
Grade 4 ¼ raised, healing normally; and Grade 5 ¼
almost invisible. Briefly, the wound was inspected for the
dehiscence percentage.
At this occasion, the rats were anesthetized as
described earlier, and the groin opened for macroscopic
and empty-and-refill test assessment. The inspection con-
sisted of visualizing pulsatile flow through the anastomo-
sis site, and the test was performed by gently milking the
distal end of the anastomosis. After that, the site of vas-
cular anastomosis was ressected and included in paraffin
for histologic analysis.
Histologic Analysis
The vascular histology was studied under light mi-
croscopy and hematoxilin and eosin stain. Perivascular
infiltrate, endothelial lesions, and lumen thrombus were
observed.
Vascular morphometric digital measurements were
performed by using a 203 objective. Intimal, medium,
and adventitial layer thicknesses were identified and
measured using a Java image-processing program (Image
J 1.31v, NIH, USA). Results are expressed as mean
(standard error of mean, SEM). Statistical analysis was
performed using t test or Mann–Whitney Rank sum test.
Data were considered statistically significant when P <
0.05.
Arterial Microvascular Anastomosis 287
RESULTS
Wound Inspection
All groin wounds were examined. Healing score was
similar in both groups (tamoxifen and vehicle groups ¼
Grade 4). There was no wound complication (Grades 4
and 5) in 100% and 70% of the animals from vehicle
and tamoxifen groups, respectively. Three animals in the
tamoxifen group had partial wound dehiscence (Grades 0,
1, 2).
Gross Vascular Assessment
After the wound inspection, the femoral artery was
dissected and observed for flow. All animals from both
groups had pulsatile flow through anastomosis. The
empty-and-refill test was also positive.
Histologic Analysis
Inflammatory infiltrate as well as mild vasculites were
observed in both groups, but it was more intense in the
tamoxifen group. The intimal thickness in the tamoxifen
group was significantly higher than in the vehicle group
(18.2 6 8.5 lm vs. 6.1 6 1.9 lm, respectively;
expressed as mean 6 SD; P ¼ 0.036, Mann–Whitney
Rank sum test). The difference was reflected in the total
vessel wall thickness, as well (tamoxifen group 153.3 6
19.9 lm vs. 122.1 6 17.2 lm for vehicle group; P ¼
0.043; Mann–Whitney Rank sum test) (Fig. 1).
DISCUSSION
Chemopreventive and adjuvant therapy with tamoxi-
fen is widely used today in pre- and postmenopausal
women with breast cancer and other solid tumors. Estab-
Microsurgery DOI 10.1002/micr
288 Pessoa et al.
lished evidence about the potential for thrombosis and
thromboembolism is well documented. However, the
exact mechanism for the thromboembolic events is not
totally understood. Reduced level of antithrombin III and
deficiencies in factor V and protein C are implicated in
the genesis of these events. Although the majority of
case-report deals with venous thrombosis, a randomized
study and some case reports pointed an increased risk in
the arterial thrombosis in pre- and postmenopausal
women receiving tamoxifen.7,14
The oral administration of tamoxifen is well tolerated
by the animals and ensures reliable levels of medication.
The pretreatment period of 2 weeks was based in the
maximal life span of rats to simulate a period of chronic
administration of tamoxifen. The period superior to 6
month of tamoxifen use is associated with a great inci-
dence of thromboembolic events.11
It was observed on our study a tendency for wound
breakdown in the group treated with tamoxifen. This
data is not corroborated by previous works. McNamara
et al. studied the effect of tamoxifen on endothelial
growth factor in vitro and did not find a real wound
healing impairment.15 Mancoll et al. found an inhibitory
effect on keloid fibroblast.16 Even though tamoxifen re-
tarded wound healing, it did not decrease the wound ten-
sile strength.
Breast reconstruction with free flaps is a reliable
and a common option after mastectomies.17 The pedi-
cle flow to the flaps is the determinant of success
and failure of the reconstructive attempt. Our data did
not demonstrate an increase in arterial thrombosis after
microvascular repair. We could not find macrosco-
pic differences in the vascular anatomy and external
observation of flow between treated and nontreated
groups.
In the histologic analysis, we did not observe intralu-
minal thrombus. A perivascular inflammatory infiltrate
was observed in both group and it did not differ with
each other. The difference in intimal thickness points to-
ward a possible tamoxifen effect favoring arterial throm-
bosis.
CONCLUSION
Our data showed that tamoxifen induced a tendency
toward inflammation. A real thrombotic effect upon the
Microsurgery DOI 10.1002/micr
arterial vascular anastomosis was not observed, even
though tamoxifen induced intimal hyperplasia.
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